1 / 88

STEMI Boot Camp III -Tools of the Trade

STEMI Boot Camp III -Tools of the Trade. David R. Burt, MD University of Virginia. STEMI Tool Kits… -Tactical Concepts. Objectives:. …Help you build a better system

dino
Download Presentation

STEMI Boot Camp III -Tools of the Trade

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. STEMI Boot Camp III-Tools of the Trade David R. Burt, MD University of Virginia

  2. STEMI Tool Kits…-Tactical Concepts

  3. Objectives: …Help you build a better system Now that you better understand the basic principles and theory behind STEMI system construction we want to discuss the tools available (at all levels) to help you optimize your individual Elemental STEMI subsystem!

  4. Remember: Building a Better System Requires Education… • FACT: Educating a provider will not fix a “broken” system… but it helps! • BUT: Fixing a system can support an “uncertain” provider • THEREFORE: Fixing the system and educating the provider ensures success!

  5. I. The (Really) Big Picture • National, community-based initiative • Goals • Improve quality of care and outcomes in heart attack patients • Improve health care system readiness and response STEMI System Blueprints …courtesy of the AHA… 5

  6. Working at all levels to improve care for STEMI patients 6

  7. AHA: STEMI System Blueprints Mission: Lifeline Recommendations for Criteria for STEMI Systems of Care The criteria are divided into: • Non-PCI Hospital/STEMI Referral Center • PCI Hospital/STEMI-Receiving Center sections • EMS • STEMI Systems of Care

  8. Please visit the Mission: Lifeline portion of the American Heart Association website for all types of ideas for improving STEMI systems of care 8

  9. II. D2B: PCI-center systems engineering The Door to Balloon Initiative (D2B), organized and spearheaded by the American College of Cardiology (ACC), was extremely successful in helping optimize STEMI care at PCI centers via its attention to systems level improvement as the key to sustainable success

  10. D2B: PCI Engineering 1. ED physician activates cath lab 2. One call activates the cath lab 3. Cath lab team ready in 20-30 minutes 4. Prompt data feedback 5. Senior management commitment 6. Team-based approach

  11. D2B: PCI-center systems engineering For more information on D2B, please visit the ACC website.

  12. III. Project UPSTART: STEMI System Builder’s Toolkit

  13. Project UPSTART: A Reperfusion Toolkit for All Situations Project UPSTART was designed as an integrated set of concepts, processes and procedures that can be used to help efficiently address issues that are common in any local STEMI system

  14. So, Optimize Recognition and Reperfusion… • All attempts at reducing STEMI treatment times must ultimately focus on improving one (or both) of these endpoints. • The goal: early Recognition followed by early Reperfusion.

  15. …By Remembering “Joe the STEMI Patient” • Systems Engineering: -Optimizing the average! • Design your system with optimism but base it on realism

  16. And Remembering the 80/20 Rule!

  17. Review: Efficient Improvement First, define and understand your local Elemental STEMI Subsystem Next, optimize the 5R’s within your local ESS & build a solid self-improving, sustainable system Finally, devote time to fine-tuning each STEMI conduit within your ESS

  18. First, Define and Understand Your ESS! PCI Non-PCI Non-PCI PCI

  19. Key Concept: The “Elemental STEMI Subsystem” (ESS) The smallest combination of EMS and STEMI treatment facilities that can function “alone” as a self functioning “STEMI system of care” By definition, the ESS is the “elemental building block” of all STEMI systems –no matter how large that “system” may be ??

  20. A Typical Elemental STEMI Subsystem

  21. Homework: Sketch Your ESS Here Please!

  22. Homework/Notes:

  23. Next, work on the “5R’s” Within your ESS In order to improve your system in a time efficient manner you must improve each one of these critical processes until they are running smoothly.

  24. Review: The 5 Essential Elements of STEMI System Design • R1 Relationships • R2 Recognition • R3 Reperfusion • R4 Real-time Data Collection • R5 Reassessment & Refinement

  25. Homework/Notes: What 2 Essential Elements do you feel need the most work within your current system? (circle 2) R1 Relationships R2 Recognition R3 Reperfusion R4 Real-time Data Collection R5 Reassessment & Refinement

  26. Finally, now sweat the small stuff!-fine-tune each STEMI conduit within your ESS.

  27. Homework: Sketch one of your problem STEMI Conduits here…

  28. Review: Efficient Improvement First, define and understand your local Elemental STEMI Subsystem Next, optimize the 5R’s within your local ESS & build a solid self-improving, sustainable system Finally, devote time to fine-tuning each STEMI conduit within your ESS

  29. Final Result: A Simple Plan

  30. Homework/Notes: • Is the current STEMI ALERT Plan in my institution this simple and defined? • How can I simplify it?

  31. The Payoff? More of Them Are “Easy” An example…..

  32. Logging, Bad Burgers & Angels • 34 year-old male is logging trees in remote area • Increased heartburn after “gut bomb” lunch • Pain worsens; His boss calls rural EMS, who arrange to meet them at a local “Kum and Go”. • EMS does ECG in parking lot: it looks “bad” • Idea: fax ECG to UVA Medical Command

  33. DX: Acute Inferior Wall MI! • EMS departs for UVA after faxing ECG • In route to UVA patient goes into ventricular arrest and becomes unresponsive • Defibrillated once and revives • EMS contacts UVA in route; discusses ECG with the on-duty ED physician • UVA Cath lab activated, ED on Standby…

  34. ED Antics • Arrives in ED …..’”groggy and painful” • 2nd IV placed/Groin prepped/Monitor • Pacer Pads placed • Beta Blocker, Heparin and Plavix • Clothes off, consented, and down the hall • ED door in to door out? 8 Minutes!

  35. Cath Lab Precision… • Cath lab staff ready at bedside! • Lido time: Cath door + 2 • Access time: door+ 12 • Cath lab door to device: +18 • Cath Lab door-to-balloon: + 21 • Total R2R time: 59 minutes from 1st ECG at the gas station • Total DTB time: 29 minutes

  36. Post Cath… • Cardiac echo shows only a minimally depressed ejection fraction • Patient feeling much better! • Admits to 5 days of increasing “heartburn” • PMH: Dad died at 50 of massive MI… • Refers to his EMS providers as the “two special angels who saved his life!”

  37. Madison County, VA -2 “EMS Angels”

  38. So, Start Somewhere…Today • Don’t wait for perfection • Start fixing the process now • Change items that really matter • Start by optimizing the 5 R’s!

  39. R1) Relationships! STEMI System Cement Recognition! Relationships Reperfusion!

  40. Homework: • Write down three relationships within your ESS that currently need attention • Note: Please refer to the Project UPSTART system assessment quiz for additional information on STEMI system relationships

  41. R2) Recognition: Develop optimal STEMI recognition practices at each STEMI “portal” Goal: Each qualifying patient receives a timely screening ECG!

  42. Optimize Recognition at Every Portal!

  43. I. EMS: “Mobile” STEMI Portals Think Logically!

  44. EMS “STEMI Vision” –Just Say No! 95%+ of EMS calls are NOT STEMI! Weak/dizzy MVA Ab Pain ??? STEMI Altered LOC

  45. EMS ECG: Keep it Simple! • Provide EMS personnel with ECG machines • Provide clear “if/then” protocols for all EMS possibilities • Provide ECG acquisition training • Provide ECG interpretation training • Provide feedback and education • Consider transmission technology

  46. First Step: Got STEMI? – Call the ED! • EMS/ED communication on every potential STEMI is a must • Either with/without ECG transmission • Ties the ED and EMS together • Will capture most cases of STEMI prior to arrival I think I got one!

  47. Simple Protocols at Each Portal Example of a simple 3-step protocol 1) In situations where EMS personnel have obtained a pre-hospital ECG suspicious for STEMI. 2 EMS personnel should immediately contact Med Com, clearly identify the incoming patient as a possible STEMI, and request to talk directly with the attending ED physician. 3) This step should occur for each suspected STEMI case—even if EMS is unable to transmit the ECG to UVA.

  48. Simple protocols at each portal

  49. ECG Transmission: Nice but not essential! ECG Transmission: “Icing on the Cake” Transmission may be useful in certain situations but does not replace more important essentials such as protocol development, EMS training and a focus on ECG acquisition as the key 1st step!

More Related